CDI Question and Answer Key GRADE A+ SOLUTION

What is a reason a physician documentation can be difficult to review? Illegible handwriting The best scientific data available for clinical documentation is also known as Evidence-based medicine The two-part theory for high-quality clinical documentation is a cause-and-effect theory that is derived from which two sources? Legal/Regulatory Sources and Peer-Reviewed Research When discussing completeness in a health record, the physician has fully addressed all concerns, as well as what other authentication? Signature and date Peer-reviewed academic literature states that this factor shows a relationship to quality of care as well as support for concurrent CDI programs: Documentation What evidence supports the lack of high-quality clinical documentation in the medical field? CDI is not taught in medical school Which item is not recommended by the HHS and the OIG for minimum compliance with clinical documentation regulations? Physicians should include vaccination records What does "reliable" in high-quality clinical documentation mean? Physician documentation supports medical treatment Which item is an important aspect of consistent high-quality clinical documentation? Creates a clear picture for subsequent reviewers of documentation Which aspect of the discharge summary is the biggest challenge to house staff, mid-level practitioners, and attending physicians as they compose the patient's discharge summary? Timeliness Which aspect of the patient's health record can a member of the house staff or midlevel practitioner create, yet ultimately needs the attending physician to confirm accuracy? Problem list Interns, residents, and fellows are physicians with lesser accountability due to their inability to act as an attending physician and are also known as ______. House staff Which two medical professionals serve as mid-level practitioners by supporting physicians in the delivery of care? Nurse practitioners and physician assistants In 1982, which aspect of medical billing/reimbursement increased the demand for accuracy and timeliness with regard to medical coding? Reimbursement was driven by codes assigned to patient care Which hands-on provider's documentation should the coder not use for final coding? Diagnostic radiologist Which practitioners, along with coding professionals, are proficient at picking up deficiencies in clinical documentation yet must focus on giving care? Nurses Which healthcare setting requires high levels of proactivity from management and clinical teams to ensure accurate and timely clinical documentation? Outpatient Which item is not an inpatient healthcare setting? Emergency department High-quality clinical documentation is the basis for what standard? Gold standard What allows the diagnostic, treatment, and response of information of the patient to be aggregated into a uniform data set? Coding What part of the health record, usually located at the end the document, provides a complete picture of the patient's diagnosis? Impression and plan What description is an aspect of the coding professionals' job? Asking the physician about any gaps in documentation that may represent an insufficiently documented diagnosis What has been called the equalizer for prospective inpatient reimbursement? Severity-based DRG What is the ultimate goal of the installation of the POA indicator? To consider severity, resource utilization, and quality indicators in reimbursement Within how many hours of discharge does the attending physician normally provide the discharge summary to the coding department? 24-48 Which form of documentation is the essence of the health record on which the coder relies? Progress notes A query is necessary when a conflict in documentation exists between an attending physician and which practitioner? Anesthesiologist What does the fifth digit "1" represent with regard to the myocardial infarction code? Current admission What is suggested as a requirement for reflection of current medical practices and supports worldwide epidemiology? New coding system A 3M study suggested that the reimbursement impact on the implementation of ICD-10-CM/PCS would be what? Minimal What is the estimated negative impact of the top 25 MS-DRGs mentioned in the text? 1.4 percent What is the first step required to determine the facility specific impact of ICD-10 implementation? Begin dual coding What is the principal tool used by CDI programs to enhance efficiency? Analytics What should the facilities interested in investing in a CDI program perform on data and documentation? Objective analysis When analyzing coding data, what system has one of the highest levels of aggregation? DRG Which reimbursement method allows for multiple assignments for each encounter and allows for the analysis of clinical documentation to remain on the coding level? APC During the review of clinical documentation, on what is it imperative to focus the review? Current provider documentation Review of inconsistencies or patterns that do not meet DRG target norms, allows this data to be used for what purpose? Clinical documentation Assessment What are the two types of data the review team should consider in the CDI analysis process? Data produced by the organization; data produced by others about the organization CONTINUED....